College of Graduate Studies
Tuberculosis (TB) Risk Assessment
MTSU ID # Last Name/Family Name First Name/Given Name TO BE COMPLETED BY A LICENSED PHYSICIAN OR QUALIFIED LICENSED MEDICAL AUTHORITY Persons with any of the following are candidates for either Mantoux Tuberculin Skin Test (TST) or Interferon‐Gamma Release Assay (IGRA), unless a previous positive test has been documented RISK FACTOR: (circle correct answer) YES / NO Recent close contact with someone with infectious TB disease? YES / NO Foreign‐born from or traveled* to/in a high prevalence area? (e.g., Africa, Asia, Eastern Europe, or Central or South America) YES / NO Fibrotic changes on a prior chest x‐ray suggesting inactive or past TB disease? YES / NO HIV/AIDS? YES / NO Organ transplant recipient? YES / NO Immunosuppressed? (equivalent of >15 mg/day of prednisone for >1 month or TNF‐a antagonist) YES / NO History of illicit drug use? YES / NO Resident, employee, or volunteer in a high‐risk congregate setting? (e.g., correctional facilities, nursing homes, homeless shelters, hospitals, and other health care facilities) YES / NO Medical condition associated with increased risk of progressing to TB disease if infected [e.g., diabetes mellitus; silicosis; head, neck, or lung cancer; hematologic or reticuloendothelial disease such as Hodgkin’s disease or leukemia; end stage renal disease; intestinal bypass or gastrectomy; chronic malabsorption syndrome; low body weight (i.e., 10% or more below ideal for the given population)] *The significance of travel exposure should be discussed with a health care provide and evaluated. YES / NO 1. Does the student have signs or symptoms of active tuberculosis disease? If no, proceed to question 2 or 3. If YES: proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest x‐ray, and sputum evaluation as indicated. YES / NO 2. Tuberculin Skin Test (TST) TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no induration, enter “0”. The TST interpretation should be based on mm of induration as well as risk factors. ** (month/day/year) Date Read: (month/day/year) Date Given: mm of induration **Interpretation: Positive Negative Result: A Tennessee Board of Regents University
MTSU is an equal opportunity, non-racially identifiable, educational institution that does not discriminate against individuals with disabilities
YES / NO 3. Interferon Gamma Release Assay (IGRA) Date Obtained: (month/day/year) Specify method: QFT‐G QFT‐GIT Other Result: Negative Positive Intermediate YES / NO 4. Chest x‐ray: (Required if TST or IGRA is positive) (month/day/year) Result: Normal Abnormal Date of chest x‐ray: **Interpretation Guidelines >5 mm is positive: • Recent close contacts of an individual with infectious TB • Persons with fibrotic changes on a prior chest x‐ray consistent with past TB disease • Organ transplant recipients • Immunosuppressed persons: taking > 15 mm/d of prednisone for > 1 month; taking a TNF‐a antagonist • Persons with HIV/AIDS >10 mm is positive: • Persons born in a high prevalence country or who resided in one for a significant* amount of time • History of illicit drug use • Mycobacteriology laboratory personnel • History of resident, worker or volunteer in high‐risk congregate settings • Persons with the following clinical conditions: silicosis; diabetes mellitus; chronic renal failure; leukemias and lymphomas; head, neck or lung cancer; low body weight (>10% below ideal), gastrectomy or intestinal bypass; chronic malabsorption syndromes >15 mm is positive • Persons with no known risk factors for TB disease *The significance of the exposure should be discussed with a health care provider and evaluated. Signature of Licensed Physician or Qualified Licensed Medical Authority Date Physician or Medical Authority Information (PRINT OR TYPE): Name: Address: Telephone: OFFICE STAMP: A Tennessee Board of Regents University
MTSU is an equal opportunity, non-racially identifiable, educational institution that does not discriminate against individuals with disabilities